Healthcare Provider Details

I. General information

NPI: 1700718236
Provider Name (Legal Business Name): DAAIYAH KHALEELAH ISLAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4242 LINDELL BLVD APT 209
SAINT LOUIS MO
63108-2984
US

IV. Provider business mailing address

4242 LINDELL BLVD APT 209
SAINT LOUIS MO
63108-2984
US

V. Phone/Fax

Practice location:
  • Phone: 310-767-6810
  • Fax:
Mailing address:
  • Phone: 310-767-6810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number5737510681
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: